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Putting form in consistent, highly-visible location in patient chart

  • Printing form on colored paper (some issues raised in discussion about implications relative to faxing/copying; goal was to cue medical records that this was a pilot form but should not be discarded)
  • Organizations with different perspectives on where to put in patient chart:
    • Putting as first page of physician progress notes
    • One unit put in MedCardx to remind RN to do it
    • First sheet in chart
    • Stapled on top of chart
    • Integrated into nursing assessment, but other hospitals raised concerns over whether that would be high-visibility site for ordering MD review

Choosing where to start

A lot of different ingredients have gone in to hospitals’ selection of where to start testing the reconciling procedures, and there has been a wide variation in their choices. For some, the emergence of a physician champion on a particular unit has dictated the choice. For others, a medication error has triggered activity in a specific location. Some hospitals combined their baseline data collection efforts with a mini-FMEA process to assess the areas with the greatest potential for problems.

The most common place for organizations participating in the Collaborative to start has been in pre-admission testing (PAT), where they can take advantage of the pre-admission contact with the patient to develop an accurate home medication list. For nursing units, there have been many provocative discussions about the advantages of starting on medical versus surgical units. Chronically ill patients on the medical floors are often at great risk because of multiple conditions, multiple medications. Surgical patients with underlying medical conditions are often on medications that will need to be re-started post-op, another significant safety risk.

While most hospitals are focusing on starting with the admission phase, there is lots of great evidence on the effectiveness of reconciling on transfer out of the ICU in preventing medication errors (see Pronovost P, et. al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003 Dec;18(4):201-205.) Peter Pronovost’s work at Johns Hopkins on reconciling at transfer from the ICU is well documented on the qualityhealthcare.com WEB site, including his measurement template. Among our collaborative participants, one of our great success stories was a hospital with an extremely large mental health population that began their reconciling implementation in the ICU, with a very powerful MD champion who consistently used the evidence of the impact that failure to re-start psychotropic meds was having on their patient population!

Starting in the ED is not usually recommended, since not all patients will be admitted and the urgency of the environment results in clinician focus on other issues. However, there are opportunities to take advantage of wait times for patients who are being admitted to start the reconciling process by developing the home medication list. See additional comments below about some of the issues connected with reconciling in the emergency department.

The most important thing, worth repeating, is, wherever you choose to start, start small
  • One or two RNs, one patient/one ordering MD, on one unit
  • Test how reconciling process can be integrated most effectively with current work processes
  • Thoroughly test forms in paper format before automating
  • Moving too fast to spread change to other areas can be a mistake; ensure smooth process first

Special issues for reconciling in the ED

Our team felt that the best place to try implementing the reconciling safety procedures would be the ED. We were wondering, is this indeed the place to start? How many institutions have begun the roll-out in their EDs?

About 11% of our ED patients are admitted to the inpatient units. My main question is whether it makes sense to use the reconciliation form for every patient, or whether it should be reserved for admissions. What are other EDs doing in this regard?

Choosing to start to implement reconciling activities in the Emergency Department may not be the best strategy. We highly recommend starting instead on inpatient units, with successful first implementations focusing narrowly on patients admitted to just one unit, or alternatively on scheduled admissions as a particular subset of admissions where the opportunity exists to develop the current medication list prior to the hospitalization. Among participants in the Reconciling Medications Collaborative, Pre-Admission Testing has been the most common starting point.

Once you’ve proven both the need for reconciling and ironed out the process issues, then moving to the ED to try to jump-start the process for patients who will be admitted would likely be more successful.

Hospitals have taken different tacks in how they approach completing reconciling forms for patients in the ED. The majority, I think, wait until they have identified that the patient will be admitted. But there are also a number who try to take advantage of wait times in the ED to ensure that the patient's home medications are identified. There can be important safety benefits from this, especially in connection with identifying adverse medication reactions that may be the cause or contributor to the ED visit (case study in our example of errors reconciling can prevent: ED patient nearly dies when hospital fails to pick up that he was taking digitalis on the admission history; allergic reaction to digitalis needing immediate treatment, but significant delay resulted).

One participating hospital where a high percentage of patient volume is through the ED reported using the ED visit as an opportunity to start patient education on the importance of carrying an accurate medication list with them at all times. They now give all patients who are not admitted a completed medication card on discharge from the ED.

In a response last year to a question about whether to reconcile for all patients or just for those being admitted, Diane Brunelle, RN, one of our Collaborative’s consulting experts who directed the reconiling safety initiatives at Holyoke Medical Center, provided the following response:

I think it is safe to say there will be more success with ED staff compliance if you perform reconciliation on those patients you are going to admit. We have found a greater success rate by doing that. However if the ED in question already uses a method to list a patient’s current medications, then doing reconciliation on all patients who come to the ED would be the way to go as then you are half way there and it would be accepted by the RNs. Many EDs do not get this info until they go to admit, so it makes sense to only reconcile if you are going to admit.

Note also that Holyoke let reconciling implementation teams work independently, adopting different forms for their ED which subsequently converged.

Automating the reconciling process

  • The benefits that can be seen from automating the reconciling process create a huge temptation to move to creating an electronic interface between the reconciling information dataset and current hospital systems, especially for organizations that have already moved away from paper systems. However, a repeated refrain during the day was to test everything completely via paper systems first. "If you can't do it on paper, don't even try it in vapor" is really important. Work out steps in the process flow, in the data flow, in roles and responsibilities and procedures first, then move to IT solutions.
  • Still, it is important to begin planning for IT solutions. Involve IT in your discussions, have them hear the learning from the tests all along, but resist the temptation to jump to solutions until the change is well tested on paper.
  • Strong interest was expressed in having Meditech hospitals working together in designing an interface to do reconciling with Meditech. Include capabilities for facilitating therapeutic interchange. One hospital provided an example of a form generated by Meditech they use to review medication orders at discharge [Good Samaritan]

The Collaborative hopes to initiate a working group to facilitate sharing of electronic solution development among participants.

Using reconciling form as an order sheet

  • Many are setting this as a long-term goal. Recommendation is to first work out the reconciling process, then use positive experience with the process to gain MD approval. Too many barriers to getting diverse group of MDs/private attendings to buy-in to using the form as an order sheet without first sorting through the various implementation issues.
  • Examples of reconciling forms used as Order Sheets, along with accompanying policies and procedures, are provided in the binder, beginning on page 49.

Improving accuracy of home med lists

  • Several hospitals have put interview questions on back of reconciling forms.
  • Still looking for reports of tests of interviewing strategies to identify specific strategies that work.
  • How do you reconcile meds in non-English speaking populations?
  • Recurring theme: Don’t accept medication lists without questioning! Many examples of errors on patient-provided lists, on med lists provided from ambulatory clinic (they’re not being maintained), on lists from PCPs.
  • Calls to retail pharmacy, getting them to fax list of meds. HIPAA concerns no longer surfacing: Communications about a patient’s medication regimen clearly fall under the definition of information necessary for patient treatment, providing safe patient care. Some hospitals include language about “you may call my pharmacy” on consent form. [Holyoke]
  • Getting patients to bring list and bottles in to surgery pre-admission screenings [UMASS]
  • Changing signage everywhere it asks patients to bring in their insurance card, also ask to bring in current, complete medication list
  • Longing for EMR as long-term solution…
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